Medical Record Numbers
The hospital’s medical records are maintained under a unit number system. Each patient
is assigned a permanent hospital number (the “unit number”) upon his/her first visit to
MGH. The number is then used for any subsequent visits to the institution.
Duplicate Medical Record Numbers
Sometimes a patient will accidentally end up with more than one medical record number.
If you find a patient who has more than one MRN and their clinical information is
fragmented, please call the Patient Index Unit at 617-726-2482 or send an e-mail.
Please be aware that combining a patient’s medical record numbers cannot be done while
the patient is in-house. Once the patient is discharged, the records will be reviewed and
merged if the patient is verified to be the same.
If your patient is in-house and has been identified as potentially having multiple MRNs, a
pop-up message will appear in the hospital’s clinical systems alerting you to this fact.
Documentation Responsibilities
When documenting in the record:
 Use black ink for all entries.
 Use layman’s terms that can be understood by any third party.
 Avoid the use of unacceptable abbreviations.
Unacceptable
Acceptable
Q.D. & Q.O.D.
Use “daily” and “every other
day”
MS, MSO4 and
Use “morphine sulfate” or
MGSO4
“magnesium sulfate”
Zero after a decimal point Do not use terminal zeros (1)
(1.0)
No zero before a decimal
Always use a zero before a
dose (.5mg)
decimal when the dose is less
than a whole unit (0.5 mg)
ss for sliding scale
Use “sliding scale”
U for unit
Use “unit”
IU for international unit
BT for bedtime
Use “unit”
Use “bedtime”
History and Physical
The patient’s history and physical examination should be completed and entered into the
record within the first 24 hours of admission and prior to surgery, whichever is first.
When a procedure is being performed, the history and physical examination may be
completed up to 30 days before the procedure is performed. When the procedure is
completed by someone other than the attending physician, a note should be completed by
the other physician indicating his or her evaluation and agreement with the described
plan.
Progress Note
Progress notes should be entered into the record within 24 hours of the visit, and finalized
within 21 days after the visit. These notes document the necessity of the patient’s stay in
an acute care institution. The attending physician or designee will enter dated, timed, and
authenticated daily progress notes documenting the patient’s progress.
Operative Report
A complete and concise operative report should be dictated and finalized within 24 hours
by the responsible physician after completion of surgery or any invasive procedure.
Discharge Summaries
A complete and concise discharge summary must be completed within 24 hours of the
patient’s discharge. The responsible physician should complete the record at the time the
patient is discharged.
The medical record remains on the patient units for 24 hours after a patient’s discharge so
that the record is available for completion.
Principal (Discharge) Diagnosis
A joint effort between the physician and HIS coder is essential to achieve complete and
accurate documentation and prompt, appropriate hospital reimbursement. A vague
principal (discharge) diagnoses that is unrelated to the reason for admission or does not
accurately identify the reason for the patient’s admission will reduce reimbursement.
The most common errors in Principal Dx are:
 Traumas: The principal diagnosis for traumas is listed as the cause of injury, a
non-specific site of injury or simply trauma rather than the specific injury that is
treated.


MD Principal Dx
Coder Principal Dx
Lightening Strike
1st degree burn, back
Polytrauma
SDH
Gun Shot Wound
Injury, iliac vein
Admitting Symptoms: Symptoms at the time of admission (in the ED) or those
most representative of the condition are listed as the principal diagnosis even
when a definitive condition is treated.
MD Principal Dx
Coder Principal Dx
Chest Pain
CAD or MI
Abdominal Pain
Cholecystitis/Choledochlithiasis
Low Back Pain
Lumbar Disk Hernia ion
Hypoxia or AMS
Aspiration PNA
Surgery Performed Listed as Principal Diagnosis: The patient’s surgery is listed
as the principal diagnosis instead of the diagnosis.
MD Principal Dx
Appendectomy
Cholecystectomy
THR
Coder Principal Dx
Acute Appendicitis
Chronic Cholecystitis
Osteoarthritis, hip
Dictation
Physicians can dictate inpatient operative notes and discharge summaries into a
computerized dictation system from any MGH touch-tone telephone. Each physician is
assigned his/her own six digit provider number with which to access the dictation system.
General Guidelines for Dictation
 Identify yourself by your full name and Department.
 State if you are dictating for another physician, however you must still use your
own individual six digit provider number
 Spell out the patient’s full name and state the patient’s
medical record number.
 Indicate paragraphs and punctuation.
 For operative notes, give the date(s) of surgery, pre-and post-operative
diagnoses/is and the name(s) of all procedures performed.
 For Discharge Summaries, give the admit and discharge dates.
 Upon completion, state the number of copies required and to whom they are to be
sent.
 You must state and spell the full names and addresses of physicians who should
receive copies.
 Cell phones should not be used for dictations
Detailed guidelines for inpatient dictation are available in the HIS Transcription
Department at 617-726-2488 and the web site https://hub.partners.org/wiki.
Inpatient Dictation System Instructions
1.
2.
3.
4.
5.
6.
Call 617-724-3125 and wait for the prompt.
Enter you six digit provider number, then # on the keypad.
To dictate press 1, to review a dictation press 3
Enter the 2-digit work type code (see below), then # on the keypad.
Enter the 7-digit medical record number, then # on the keypad.
To start to record, press 2 (you will hear a continuous tone that stops when you
begin to dictate.).
7. To end the dictation, press 5, and hang up.
Work types
11- Operative Reports
22- Discharge Summary
66- STAT transfer summary: (to be used only when a patient is being transferred
to another healthcare facility)
Incomplete Records
Records not completed on the Patient Care Units or in the Same Day Surgical Unit are
filed in the Incomplete Area within the Health Information Services Department on the
8th floor of the Founders Building 617-726-2490. A weekly listing of incomplete records
is compiled and a notification e-mail is sent to each responsible physician.
Delinquent Records
When a record remains incomplete for 14 days or more, it is considered delinquent.
If you have 3 or more delinquent records or any delinquent dictations you are eligible for
suspension. Suspension allows the physician time to complete their delinquent records.
The following privileges are not allowed during suspension:
 Admitting Privileges
 Operating Room Privileges
 Billing Privileges
Any questions or problems about incomplete records should be immediately discussed
with the Record Completion Department at 617-726-2490.
Requesting Records
Patient Care
Immediate Record Requests for a patient’s MGH paper medical record for patient care
purposes may be made by calling the Record Control Center at 617-726-2477
Research
All records requested for research may be reviewed only in the Doctors’ Reading Room.
Records may not be removed and must be reviewed within two weeks or they will be
returned to the file. A maximum of 20 Record Request Slips are accepted at one time.
These can be sent via telephone, email, or fax.
Returning Records
Inpatient Records
Inpatient records should not be put in return boxes or sent through house mail. HIS picks
up patient records that are left on the unit and delivers them to Record Processing for
analysis, coding and completion.
Outpatient Records
Outpatient records should be returned to the Record Control Center by calling 617-7242477 to request that the records be picked up.
Transferring Records
As records are needed throughout the institution for a variety of reasons, it is imperative
that HIS know the location of all records at any given time. Users are therefore requested
to inform the department whenever they “lend” a record that is currently in their
possession. Medical records can never leave the MGH campus.
Release of Medical Records
Medical record information is considered confidential and should not be discussed with
anyone except the patient without appropriate written authorization.
Outpatient Records
Patient and third party requests for medical records, including photocopies, should be
directed to the Release of Information Unit of the Health Information Services
Department at 617-726-2361.
Inpatient Records
When a current inpatient requests to see a copy of his or her medical record, refer the
patient to his or her attending physician.
Faxing Information
Patient information should not be faxed outside the institution. Refer all requests for
faxed patient information to the Release of Information Department’s on-site fax number
at 617-724-4559 or they can call 617-726-2361.
Electronic Copies of Medical Records
Occasionally a patient may request an electronic copy of their medical record information
instead of a paper copy. These inquiries or requests should be directed to the on-site
Release of Information Unit at 617-726-2469.
Disability Forms/General Relief/Welfare Forms
The Release of Information Unit is not responsible for completing insurance disability
forms or General Relief/Welfare forms. These forms are to be completed by the
physician. Requests for copies of medical records to accompany a disability/general
relief/welfare form can be referred to the Release of Information Unit.
If you have any questions about the release of medical records, call the Release of
Information Unit at 617-726-2361 and refer to the medical record policies in the Clinical
Policy and Procedure Manual.